Paediatric Anaesthesia 1998 8: 485–489

Paediatric day case anaesthesia: estimate of itsquality at home

B. GRENIER, MD∗ , M. DUBREUIL, MD†, D. SIAO, MD∗ ANDY. MEYMAT, MD†∗Department of Anaesthesiology 3 and †Department of Anaesthesiology 4, Hopital Pellegrin,33076 Bordeaux Cedex, France

SummaryThe aim of this clinical audit was to evaluate the home recovery andcomplications of 104 daycase anaesthetized children, as well asparent satisfaction. A questionnaire, explained at the time ofpreoperative visit, was given to parents at hospital discharge andreturned by mail. Opioids were administered in 19% of the childrenwhereas regional anaesthesia was performed in 28% of cases. In therecovery room, 8% of them suffered pain. At home, pain was themain problem (25%) and vomiting and agitation were found in 9%and 6% of the cases respectively. Parents reported anxiety in 45% ofcases, and 14% called their general practitioner. Nevertheless, 94%were satisfied with the anaesthetic. A clinical audit is useful indetecting management deficiencies. Quality of home recovery maybe improved by: wider use of perioperative analgesia, systematicprescription of take-home analgesia, designation of a hospitalpractitioner for advice, and closer collaboration with generalpractitioners.

Keywords: day case surgery: recovery; quality

Introduction infrequent, but minor incidents and discomfort arecommon. Nevertheless, few studies aim to evaluate

Paediatric outpatient anaesthesia is frequent and safe.the quality of recovery after the patient has returned

Indeed, there is a move to increase the proportion ofhome.

operations carried out as daycases, on the basis ofThe aim of this study is to assess the home recovery

efficiency and resource management. Thus, in manyand comfort of children who have undergone day

hospitals, about 40% of surgical patients undergocase procedures, as well as their parents’ satisfaction.

their operation as a daycase. In addition to theadvantages observed in adult daycase surgery, afurther advantage in paediatric practice is a reduction Methodsin separation between children and parents (1).Life threatening postoperative complications are An open study (clinical audit) was undertaken

between November 1993 and March 1994. Parentalconsent was obtained in all cases. All children who

Correspondence to: M. Dubreuil, Departement d’Anesthesie-fulfilled the usual criteria for paediatric outpatientReanimation 4, Hopital Pellegrin-Enfants, 33076 Bordeaux Cedex,

France. procedures (2) were included. Patients were excluded

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486 B. GRENIER ET AL .

if they were born prematurely, aged less than eightmonths, sustained an acute upper respiratory tractinfection or were kept in hospital and considered asinpatients instead of being discharged. Patients forwhom the data were incomplete were also excluded.A questionnaire presented and explained duringthe preoperative visit was given to parents beforehospital discharge. It was accompanied by a stamped,addressed envelope. This questionnaire aimed toevaluate complications at home (including pain) OthersOrthopaedics

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reported by parents as well as their appraisal and Figure 1Anaesthesia technique according to surgical procedures.reaction. The follow-up evaluated the first 24 h∆ General anaesthesia; Φ regional anaesthesia.postoperatively. The following items were used to

assess complications: agitation, apathy, sleepiness,difficulty with sleeping, vomiting, oral intake refusal, period. Eleven children were excluded because two of

them were considered as inpatients (one respiratoryfever, hypersalivation, moaning, crying and pain. Forthe parental appraisal, the items were: calls for their complication, one because parents found that their

child was ‘apathetic’) and nine because of incompletegeneral practitioner or any other medical advice,anxiety, opinions about the anaesthetic and about day data. The 104 included children mean age was

7.2±4.6 yrs (8 months–15 years), with a majoritycare management. Patient data were also collectedduring the hospital stay. Details of the preoperative of boys (73%). Past medical history revealed rather

frequent (37%) ENT and/or bronchopulmonaryassessment, duration of preoperative fasting, pre-medication, anaesthetic management, surgical pathology (repeated tonsillitis and otitis media,

asthma and bronchiolitis) but 91% of children wereprocedure and its duration were recorded. Theanaesthetic technique was left to the discretion of ASA 1. Only one preoperative chest x-ray was

performed. Premedication was given to 96% of thethe attendant anaesthetic consultant. In the recoveryroom (RR), length of stay, Aldrete recovery score (3) children when they arrived at the outpatient ward.

Midazolam was administered orally or rectally (0.2and complications were also registered. Childrenwere allowed to leave the RR, to the outpatient to 0.5 mg·kg−1), with or without atropine in the form

of a rectal gel (0.02 mg·kg−1) manufactured by theward, when the Aldrete score was above 8. Hospitaldischarge was authorized by the anaesthetist and the hospital pharmacy. Total duration of hospitalization

was 6.6±1.7 h (4.8–8.7 h). Surgical procedures andsurgeon when the usual discharge criteria in day casepaediatric practice were met (2). anaesthesia techniques are shown in Figure 1. The

mean duration of the procedure was 35±17 minA trial period in the use of the questionnaire wasundertaken by all the anaesthetists in the audit, in (10–80 min). Induction of anaesthesia was performed

with volatile (halothane) or intravenous (propofol)order to standardize the presentation and explanationof it to parents. The results of this period are not anaesthetic agents. In all of the cases, anaesthesia

was maintained with volatile anaesthetic (halothaneincluded.Data were analysed with the EPI INFO⊂ statistical or isoflurane). Twelve children (11%) were intubated,

whereas a laryngeal mask airway was inserted inprogram. Quantitative data are summarized asmean±standard deviation (range). Categorical vari- 59 others (57%). Ventilation was controlled in 40%,

and spontaneous in 61% of the cases. Peroperativeables were compared by a McNemar test or a v2

analysis with Yates correction when appropriate. analgesia techniques included regional anaesthesiaand intravenous narcotic (Table 1). At the end ofSignificance was assumed when P<0.05.surgery all children were admitted to the recoveryroom, with a mean duration of stay of 65±28 minResults(30–165 min). Arterial desaturation (SpO2<95%) wasnoted in one case, and vomiting in four cases.This study collected 115 files which represented 74%

of all the paediatric day cases during this five months There was no other respiratory event except from

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QUALITY OF PAEDIATRIC DAY CASE ANAESTHESIA 487

Table 1 anxiety (45%) and telephoned their generalPeroperative analgesia techniques practitioner in 14% of cases. Nevertheless, 94% were

satisfied with the anaesthetic.n %

Intravenous opioid 20 19.2Discussion

Nalbuphine 8This study revealed that per- and postoperativeDextromoramide 4

Alfentanil 4 respiratory events were rather rare and contrastedFentanyl 4 with the frequency with which we obtained a history

of ENT and/or bronchopulmonary disease. ChildrenRegional anaesthesia 28 26.9were premedicated more frequently (96%) than is

Caudal analgesia 12 usually reported in the literature (4). Few childrenPenile block 11 received peroperative opioids or regional anaes-Upper limb blocks 3

thesia. Although it was not specifically evaluated,Others 2this attitude may be due to a fear of postoperativeopioid respiratory depression, or the fear of aprolonged block following regional anaesthesia. Thisattitude is not without consequences, as about 8% ofuncomplicated episodes of cough. Agitation, notthe children suffered from pain on leaving the RRrelated to hypoxia, was present in 15% of cases. Painand 25% of the parents reported pain at home. Aldretewas present in 8% of the patients as they left the RRrecovery score does not take into account post-for the outpatient ward.operative pain, which may allow children to leaveThe return rate of the questionnaire was 95%.the RR with pain (it also takes no account of arterialTwenty-five per cent of the children were noted todesaturation). Thus, it seems that a more specifichave suffered from pain. Two thirds had pain relatedscore would be necessary to get a better evaluationto their surgical wound, and one third had head-before discharge from the RR. The Kremlin-Bicetreaches. Pain was significantly more frequent at home,Hospital Score (KB Score), created for adult surgerycompared with that in the RR. Moreover, it was more(5), could be used for children. It takes into accountfrequent (41% vs 15%, P<0.05) in children who didpostoperative pain, hypoxia, vomiting, bleeding andnot receive any opioid or regional anaesthesia (Figureagitation. This score is currently under evaluation2). The frequency of pain was similar when opioidfor the children in our centre.or regional anaesthesia were given (15% vs 14%).

A high questionnaire return rate was achievedAgitation (6%) and vomiting (9%) were the other(95%), making the reported results on parents’ viewscomplications reported by parents. Parents reportedmore reliable than in previous similar studies. Indeed,using telephone and mail, some authors reported acontact rate of only 50% and 33% respectively (6,7).The success of our questionnaire seems due to anadequate trial period, resulting in better cooperationfrom the medical team, and to the contact with,and explanations to, the families at the time of thepreoperative visits. Few studies in the literature aimto evaluate the postoperative complications occuringat home after paediatric day case anaesthesia (6).During a period of 39 months, Patel & Hannallahstudied 9910 children admitted for an ambulatoryprocedure. Parents were interviewed by telephone.Answers were obtained in only 50% (i.e. 4998

Figure 2children). The rate of complications was 34.5%, whichRelative frequency of pain at home according to anaesthesia

techniques. ∆ Patients with pain; Φ patients without pain. included vomiting (8.9%), cough (6.5%), drowsiness

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488 B. GRENIER ET AL .

(5.9%), sore throat (5.1%), fever (4.7%) and persistent anaesthetics alone had been found to be faster thananaesthesia with opioids, but there was no differencehoarseness (3.4%). Other problems were represented

by headache, bad dreams, muscle pain, loss of in the time to RR discharge (12). Secondly, followingdischarge, there is inadequate provision for com-appetite, dizziness and upset stomach. In our study,

the incidence of postoperative vomiting (9%) is munication between the parents and the hospital.This is a pity, as it does not continue the goodsimilar to that reported by Patel & Hannallah (6),

but lower than the incidence reported by others relationship between parents and anaesthetistsestablished at the time of the preoperative visit. Since(8,9). This could be due to differences in surgical

procedure, as strabismus surgery and tonsillectomy the end of this clinical audit, we have modified themanagement of children receiving day case surgerywere not performed in our study, and are associated

with a greater incidence of vomiting. Nevertheless, in our hospital. All our paediatric anaesthetists havebeen sensitized to the importance of postoperativepain is the dominant problem (25% of the patients).

It is noteworthy that children who did not receive pain, and to the need to promote the use ofperioperative analgesic techniques. An individualperoperative analgesia (opioids or regional analgesia)

suffered significantly more at home than other prescription for take-home analgesics is provided toall patients. Parents are also given a list of telephonechildren.

This audit revealed that patients did not receive a numbers, which enables them to seek advice from ahospital practitioner at any time during the first 24 hsystematic prescription of analgesics to cover home

needs on hospital discharge. Thus, perioperative pain following discharge. Our last objective would be todevelop communication between anaesthetist andmanagement is inadequate, and needed review with

the aim of improving the quality of recovery, general practitioner.Some authors recommended including nurses withincluding the period at home. With this in mind,

an analgesic (paracetamol, nalbuphine or a NSAID) paediatric training (13). These community basednurses, belonging to the outpatient paediatric unit,given with premedication or a regional technique

when indicated, could be useful, especially con- would undertake to visit the children in the first 24 hafter their return home. This management wouldsidering the concept of preemptive analgesia (10).

Pain, followed by agitation and vomiting, were the offer real feedback on children’s behaviour at home.The great majority of families are satisfied withreasons for anxiety in parents. One in six parents

responded to this by calling their general practitioner. paediatric outpatient anaesthesia, even whenproblems occur at home. This clinical audit hasThis may be due to the absence of a designated

hospital practitioner whom parents might contact revealed possible insufficiencies in a team’smanagement and has provided the basis to improvefor advice or reassurance. It is paradoxical that we

obtained such a good satisfaction rate (95%). This the overall quality of patient care. Control ofpostoperative pain, as well as collaboration betweenmay be due to the overiding desire and expectation

of parents that their child should recover at home as hospital, parents and general practitioners, are thekey factors. Improvements should be reevaluated inplanned so that, by allowing this, even at the expense

of some discomfort and anxiety, the initial ‘contract’ the near future.made at the time of preoperative assessment was

Acknowledgementsfulfilled.This clinical audit revealed two major insuf- We thank Dr Mireille Berthoud-Birthwisle,

ficiencies in our management of day case paediatric Department of Anaesthesiology, Hallamshire Royalpatients. First, that the use of intraoperative analgesia Hospital and Sheffield Anaesthesia Universitywas probably inadequate. Indeed, we found that pain Department, Sheffield, UK, for her valuable andat home was more frequent in children who did not critical review of the manuscript.receive any sort of analgesia perioperatively. Thismay be due to an unjustified fear in day case surgery, Referencesalthough Burns et al. demonstrated that regional

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